Surgical treatment for breast cancer has evolved from the original Halsted radical mastectomy to the segmental mastectomy, which was shown to be effective breast cancer therapy through trials as early as 1985. Since that time, breast-conservation therapy (BCT) via segmental mastectomy or lumpectomy and postoperative radiation therapy have become the treatment of choice in early-stage breast cancer, including stage I, IIA, or IIB.1 By current standards, almost three-quarters of breast cancers now qualify for BCT.2,3
Along with advancements in BCT, the melding of oncologic and reconstructive procedures has produced what is known as oncoplastic surgery and tumor-specific immediate reconstruction (TSIR) of the breast.4 TSIR, defined as reconstruction to restore symmetry after partial mastectomy or lumpectomy, has been carried out in various forms for over two decades. Reduction mammoplasty also provides opportunity for quadrantectomy, which may serve to improve local resection and decrease local recurrence rates.5 The specific combination of breast reduction with lumpectomy or partial mastectomy in the macromastic patient has been shown in several studies to be both aesthetically beneficial and oncologically sound.6 Breast reduction as an oncoplastic approach may provide a better alternative surgical option for women with macromastia with optimal cancer treatment and reconstructive outcomes.
Reduction mammoplasty techniques rely on resection of breast tissue surrounding a vascularized pedicle. This pedicle can be based in various locations depending on the regions of breast tissue undergoing resection. Oncoplastic immediate reconstruction using mammoplasty techniques begins by preoperative quadrant localization of the tumor and estimation of the resection size required to obtain complete tumor excision compared to the total breast volume. Figure 152-1 provides a classification system for different tumor locations. Once the location and size of the resection have been estimated, the surgeon can then proceed to identify an appropriate pedicle location and pattern of skin incision.
Classification of anticipated postsegmental mastectomy breast defects by tumor location.
Knowledge of breast blood supply is perhaps the most relevant anatomy with respect to the reduction mammoplasty technique. Blood supply to the breast is primarily via perforators from the internal mammary and anterolateral intercostal and anteromedial intercostal arteries. The breast skin maintains viability through the subdermal plexus and the above noted perforators. Interruption of either the subdermal plexus or the primary perforators can lead to breast skin necrosis, namely in the setting of lengthy skin flaps. Conversely, the nipple-areolar complex (NAC) is supplied by a robust subdermal plexus allowing for NAC viability based solely on an underlying vascularized pedicle of breast tissue. Sensation to the NAC is via branches of the third through fifth anterolateral and anteromedial intercostal nerves with the greatest contribution from the fourth intercostal nerve. The reduction mammoplasty techniques often sacrifice one of the above noted sources ...